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Which of these categories best describes what your business does?

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Healthcare

Education

Transportation / Aviation / Aerospace

Financial Services

Real Estate or Property / Construction

IT

Hospitalities (Hotels & Casinos)

Food Production or Agriculture

Retail or Restaurants

Pharmaceuticals

Mining & Primary Industries

Energy

Telecommunications

Utilities

Manufacturing

Legal Services

Business & Professional Services

Defense / Military Contractor

Non-Profit

Entertainment & Media

Other

Tell us about your company

What is your company name?

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Annual Revenue:

What Protected Records do you process or maintain?

Select all that apply:

Healthcare RecordsWhat are Protected Healthcare RecordsProtected healthcare Records means the total number of individuals for whom you store, process or maintain records relating to healthcare information of any type. Examples include medical history, medical reports, insurance information, procedure codes, and test or lab results.

How many healthcare records?

Personal Information RecordsWhat are Protected Personal Records?Protected Personal Records means the total number of individual for whom you store, process or maintain financial account numbers or government identification numbers. Examples include driver’s license numbers, passports or other government identification number, bank account numbers, brokerage or trade account numbers, FEIN, EIN or equivalents. Not credit or debit card numbers.

How many personal information records?

Payment Card Transaction RecordsWhat are Payment Card Transactions?Payment Card Transactions means the total number of debit or credit card transactions that you process annually on transaction systems operated by you or by others on your behalf if under your operational control.

How many payment card transaction records?

Are you or your credit card processing venders PCI Compliant?PCI CompliantThe payment card industry data security standard (PCI DSS) applies to companies of any size that accept credit card payments. If your company intends to accept card payment, and store, process and transmit cardholder data, you need to host your data securely with a PCI compliant hosting provider or, if you do not host your data, use a credit card processing vendor that is PCI compliant.

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Approximate # of records = 0

Have you experienced a theft or unintended release, disclosure or loss of protected records in the past three years?

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Please specify the details of the claim, suits or proceedings:

Coverage Options

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$1 million in coverage with a $2,500.00 deductible $2 million in coverage with a $5,000.00 deductible $3 million in coverage with a $10,000.00 deductible